That said, mental distress is unusually and persistently common in some states, whether due to economic troubles, lack of access to health care, or other factors.

Using data from federal health agencies, Health.com has identified the 10 states with the highest rates of depression, psychological distress, and other indicators of poor mental health. Here they are, in alphabetical order.

I was less than surprised to find both Kentucky and West Virginia listed. (“Like the many other rural southern states on this list”#) I’ll focus mostly on those two, being the most familiar with actual conditions on the ground there.

What are some of the factors that get pointed to in the piece?

Rates of depression and other mental-health problems are higher than the national average throughout the mountainous and sparsely settled region known as Appalachia. They are higher still in the coal-mining areas of central Appalachia, which includes most of eastern Kentucky.

Poor mental health in Kentucky is part of a constellation of social problems that includes high joblessness and drug abuse. “When people don’t have good jobs to support families, I think that leads to depression and anxiety, which in turn leads to substance abuse,” Kentucky Governor Steve Beshear told the AP in 2008.

I can’t find much to argue with there, other than the usual “sparsely settled” or “not severely overpopulated yet” perspective thing. Similar factors apply, from what I understand, to many reservations and the Welsh Valleys. (“With rising unemployment, youths are using and dealing drugs as a way of getting by. ‘Where there is no hope,’ the saying goes, ‘there’s always dope.'” And I had to think of a couple of nearby counties back home. :-|)

Here’s an interesting and very relevant illustration I shared a while back on Tumblr*:

Talk about the picture of inequality:

I’m not up to doing a description right now. But, yeah, I grew up in [or on the edge of] the red blob there in Virginia with family in, erm, all the rest of the adjoining dark red district blobs. Including Rogers’ district.

And, yeah, as the original piece points out in a couple of places, indicators of physical and mental/emotional well-being tend to go together. *gasp* If not quite as simply as described elsewhere in the piece**:

Like Mississippi, Tennessee also has high rates of chronic diseases such as obesity and diabetes, the stress of which can worsen depression. As many as 70% of Tennesseans who see a primary care physician for obesity, diabetes, or hypertension meet the criteria for depression, anxiety, or other mental disorders, the state’s mental health commissioner has estimated.

All of these things have connections to chronic stress and (ultimately) inequality, and they can feed into one and reinforce another in pretty complicated ways. But, back around to West Virginia:

The Mountain State is ranked last or next-to-last in every mental-health category on our list, including the average number of “mentally unhealthy” days residents have per month and the percentage of people who experience frequent mental distress (15%).

One reason may be that roughly two-thirds of West Virginians live in rural areas, where both steady jobs and access to mental health care can be hard to come by. A 2000 study found that while nearly 1 in 3 residents living in rural areas had “a high level” of depression symptoms, almost half had never been treated for the condition by any doctor, let alone a psychiatrist or mental-health specialist.

So, they’ve been decent about saying that things like poverty, unemployment, shitty infrastructure, and no reasonable expectation that the situation will improve can leave people in some kind of mental distress. How about that?!

But, of course, they continue to treat this as individual mental illness, best approached through better access to mental health services. (Note: As I have pointed out before, I am all for people being able to get the kind of help that is actually helpful, most recently here.) Trying to fix the systemic problems that are harming people–including by making them depressed–does not even get a mention, which seemed particularly baldly ridiculous and harmful in this context.

As I have seen on a more personal level, getting medicated and/or run through counselling on the premise that the only real problem is how you’re thinking about a shitty situation, will not help much while you are still living in said shitty situation. Medicalizing people’s predictable reactions to living in a bad situation just does not help. The situation is the problem, and it very predictably filters down. (See also the video on duyukta/tohi (health/well-being) at the bottom of the post here; if there’s imbalance at one level, it’s hard to find balance at another.) I don’t want to sound overly harsh, but an awful lot of mental health professionals could also do with reading Barbara Ehrenreich’s Bright-sided. But, yeah, I am one of the sufferers of that Dread Appalachian/Native Fatalism. (“[I]t may also be interpreted as a realistic understanding of life circumstances.”# You can’t predict or personally control everything that happens–amazing concept, ain’t it? :-|)

Poorer people who are maybe relying on Medicaid to get help are also much more likely to be heavily medicated rather than receive therapy, because it’s considered more cost-effective. (Not to mention easier. This also applies to adults.) Adding sometimes very unpleasant drug side effects and the stigma of mental illness to an unchanged situation and unchanged coping skills is not very likely to make a person feel better in any way whatsoever.

On that note, I also have to question the estimation of prevalence of depression symptoms, since I have personally been assumed to be clinically depressed when I was not, and so have a number of my family and friends. Part of “actually helpful” can be cultural appropriateness there.

Farthing, a man whose characteristic pessimism and gloomy perspective were interpreted as serious clinical depression, was led on a nightmare journey through the American psychiatric system. Doctors described Farthing as suffering from pervasive negative anticipation: a belief that everything will turn out for the worst, whether it’s trains arriving late, England’s chances of winning any national sports events, or his own prospects of getting ahead in life. The doctors reported that the satisfaction he seemed to get from his pessimism was particularly pathological.

“They put me on everything—lithium, Prozac, St. John’s wort,” Farthing says. “They even told me to sit in front of a big light for half an hour a day or I’d become suicidal. I kept telling them this was all pointless, and they said that was exactly the sort of attitude that got me here in the first place.”

Dr. Isaac Horney, a psychotherapist, explored Farthing’s family history and couldn’t believe his ears. Farthing spoke of growing up in a gray little town where it rained every day, of treeless streets lined with identical houses, and of passionately backing a football team that never won. Although Farthing had six months of therapy, he mainly wanted to talk about the weather. “I felt he wasn’t responding to therapy at all,” says Horney, who recommended electroconvulsive therapy.

But, yeah, especially if you really are dealing with people who are having difficulties, a lack of cultural competence in mental health care is only going to make the situation worse. BTDT, coming from a cultural background which actually seems more significantly different from US (assumed) monoculture than British cultures are. What you’re considering “normal” and “functional”–and how best to achieve this–really does make a difference.

I should maybe point out explicitly that I am not minimizing the problems of trying to deal with depression; far from it. Nor am I suggesting that nobody should seek professional help, if they think it might prove helpful in coping better. What I am saying here is that if we actually want people to feel better and be healthier, we need to focus on what is causing these problems in the first place, and try to make sure that people have the supports they need to be healthy and happy. I also think we could do with more liberation psychology-type emphasis.

Running out of steam here, so I will leave a few links. (I’ve only skimmed the couple of longer papers.)

In fact, it turns out that not only disease, but a whole host of social problems ranging from mental illness to drug use are worse in unequal societies. In his latest book, The Spirit Level: Why More Equal Societies Almost Always Do Better, co-written with Kate Pickett, Wilkinson details the pernicious effects that inequality has on societies: eroding trust, increasing anxiety and illness, encouraging excessive consumption.

The good news is that increased equality has the opposite effect: statistics show that communities without large gaps between rich and poor are more resilient and their members live longer, happier lives…

[from Wilkinson] In fact, in more unequal societies, these problems aren’t higher by ten or twenty percent. There are perhaps eight times the number of teenage births per capita, ten times the homicide rate, three times the rate of mental illness…We know from the findings that it’s the status divisions themselves that create the problems. We’re not making a great leap to say that this is causal. We, I think, show that it’s almost impossible to find any other consistent explanation.

More than 400,000 new people receive disability benefits every year since the start of the recession. And the Appalachian region has one of the highest disability rates in the country.

A spokesman for the Center for Rural Strategies said the highest rates are found in counties and areas that focused on industries like mining, forestry and agriculture. He said as those jobs have dried up, workers have had trouble maintaining steady work and the access to health care has declined. One Social Security attorney in another state said some beneficiaries might not even need disability if they could have had reliable access to good health care.
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(Bolding added.) Those are also all dangerous industries, where people tend to get injured and exposed to all kinds of nasty stuff entering the environment. Especially from mining. Throw in health conditions related to chronic stress–including from job loss, poverty, and environmental degradation–and no wonder there are high rates of disability, and people needing benefits in order to survive. [Including for “invisible disabilities”, including various forms of mental distress.]

Over the last several months, he’s pushed policies that would make college less affordable, cut access to child nutrition programs, reduce opportunities for energy efficiency jobs, and block safeguards for our water and air. He has no job creation proposal. His positions put many families further at risk, allow additional degradation of our land and water, and do nothing to improve the quality of life for Kentuckians.

Since Rogers first came in office in 1981, an estimated 300 mountains and nearly 600,000 acres of hardwood forests, and hundreds of miles of headwater streams, have been irreversibly destroyed by mountaintop removal strip mining. In the process, more than 60 percent of the coal miner jobs have been stripped by the heavily mechanized operations, leaving the local economies in ruin and without any hope of economic diversification.

** This is also where the dread “obesity and diabetes” cluster is very different from how it’s usually presented. Being fat is not some kind of disease in and of itself, but various things that mess with your endocrine system (including chronically elevated stress hormones) can make people gain weight and get sick. As can flat-out food insecurity, and poor nutrition from that.

Thanks for the lengthy blog! I believe one must be careful about lumping too much onto rurality. Yes, living in rural environments can be bad for one’s health. It can also be good for one. Vermont is one of the most rural, and healthiest states. I believe there are a few more. This is, of course, always a precarious condition. Thinks can fall apart (go south?) tomorrow. Life for some remains very challenging. Perhaps we are simply less economically hierarchical. There is a common saying, that is also a joke: What is your third job? This reflects our high cost of living and relatively low wages across the board. We ty to build and maintain community, make mental and physical health care available to as many as possible, and support each other in time of need. We have large refugee populations in some communities, and this creates tensions. Yet somehow we still are largely a good place to live. I wonder what makes the difference.